OPA COVID-19 Pharmacy Technician Relief Submission Form

In order to expedite the posting of your availability, please fill in the information requested below.

Last Name

First Name

Preferred Phone

Preferred Email

Home Address

Address

City

State

Zip

Work Address and Information

Work Title

Company Name

Address

City

State

Zip

Work Phone

I would be willing to work as a relief pharmacy technician in the following settings (select all that apply):

Community Pharmacy Practice

Health-System Practice

Long Term Care Practice

Other

Other (please specify:)

I am a certified pharmacy technician in the State of Ohio:

I am registered and in good standing with the State of Ohio:

By checking this box, I agree to have my name, city, email, and phone number publicly listed and shared on the Members Only page of the OPA website. I will contact the OPA office if I wish to be removed from this list.